Guidelines for the management and triage of avalanche victims, particularly with regard to the possibility of deep hypothermia following prolonged burial. Adapted for the New Zealand environment from the original IKAR-CISA recommendations by P Davis 2002

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Guidelines for the management and triage of
avalanche victims, particularly with regard to
the possibility of deep hypothermia following
prolonged burial.Adapted for the New Zealand
environment from the original IKAR-CISA
recommendations by P Davis 2002
www.ikar-cisa.org
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Staging of Hypothermia

• Stage 1 Clear Consciousness With Shivering
  C 35 32
• Stage 2 Impaired Consciousness Without
  Shivering 32 28
• Stage 3 Unconsciousness 28 24
• Stage 4 Apparent Death 24 - 15 ?
• Stage 5 Death due to Irreversible Hypothermia
  lt 15 ?

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Dead or Alive?

• STAGE 4 STAGE 5
• Clinical findings No vital signs No vital
  signs
• Chest Compressible Not compressible
• Abdominal muscles Pliable Not pliable
• ECG V fib or Asystole Asystole
• Core temperature Above 15Celsius (?) Below
  15Celsius (?)
• Serum Potassium
• (in the nearest hospital) Below 12 mmol /l
  Above 12 mmol/l

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Principles of extrication

• Short burial (35 min) ?
• RAPID EXTRACTION
• Prolonged burial (gt35 min) ?
• CAUTIOUS EXTRACTION

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Location and extraction of the patient

• Get the emergency physician and/or paramedic to
  the scene immediately on location, not just on
  recovery.
• Look out for an air pocket ( any cavity in front
  of the mouth and nose, no matter how small,
  provided the airway is clear).
• Avoid any destruction of an existing air pocket
  during extrication! Don't dig vertically from
  above but diagonally from the side in direction
  of the buried victim.
• Absolutely avoid unnecessary movements of trunk
  and of main joints (shoulder, hip and knee). If
  movements cannot be avoided, carry them out as
  slowly as possible.

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Patient alert or drowsy

• Change wet clothing without unnecessary movements
  (cutting).
• Hot sweet drinks as long as swallow reflex
  preserved.
• Nearest hospital with intensive-care unit.

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• Note that when a victim has been completely
  buried, even if they are conscious
• admit to hospital for close observation for 24
  hours
• because
• respiratory complications can arise later
  (aspiration pneumonia, pulmonary oedema)

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Patient unconscious

• Intubation whether a hypothermia stage III
  patient has to be intubated at the site of the
  accident or not, is still a matter of discussion.
  The risk of further heat loss during the time of
  treatment and transport has to be evaluated.
• Be ready to commence resuscitation.
• Hospital with intensive care unit and hypothermia
  experience or (preferably) unit with
  cardiopulmonary bypass.

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Patient not breathing

• Exclude obvious fatal injuries.
• Start cardiopulmonary resuscitation, intubate the
  patient.
• Check burial time and/or core temperature.
• Asystole triage only by the emergency physician
  or paramedic, aiming to differentiate hypothermia
  stage IV
• (HT IV) from asphyxia, and to bring patients
  with HT IV to a hospital with cardiopulmonary
  bypass for rewarming.

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Asystole or Stage IV?

• Criteria
• Burial time
• Core temperature
• Air pocket
• Airway.

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Triage Of Avalanche Victims With Asystole

• Obvious lethal injury
• Burial time greater than 35 mins
• Core temperature 32C or greater
• Absence of air pocket
• Asystole
• DEATH ?

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Practical prevention of further heat loss in the
field

• a) 2 to 3 chemical hot packs near the heart on
  thorax and upper part of abdomen, not directly on
  the skin.
• b) Before removing the patient prepare the
  stretcher with 2 wool blankets and 1 aluminium
  foil blanket.
• c) On removing the patient avoid excessive
  movements.
• d) Wrap up the patient closely packed in the
  blankets and in the aluminium foil blanket.
• e) Cap (30 - 50 of body heat gets lost over the
  head).

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